Psychiatric History
Please briefly describe the issues and problems with which you need help. Include obstacles to solving the
problems.
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How long have you had the problem or issue?___________________________________
In what ways is your family sympathetic or unsympathetic? _______________________
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Have you had any recent stressful life events? ___________________________________
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Write anything you wish to tell about your life. You may include: Events that gave you joy or
disappointment, educational goal/achievements, travel, books or people that influenced you.
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Primary caregiver in childhood and adolescence
Age
Primary caregiver(s)
___
_______________________
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_______________________
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_______________________
Other living in home
______________________________
______________________________
______________________________
Describe parental relationships during childhood and adolescence
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Rocky Mountain Psychiatry
303.750.2082
Describe family relationships during childhood and adolescence
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Describe your current relationships (include strengths and problems) with:
Spouse/Partner_____________________________________________________________________
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Spouse/Partner’s family__________________________________________________________
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Mother________________________________________________________________________
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Father__________________________________________________________________________________
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Children________________________________________________________________________________
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Siblings_________________________________________________________________________________
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Rocky Mountain Psychiatry
303.750.2082
Substance Use History (check and complete for all that apply):
Drug
Frequency/Amount
Route of
Administration
Duration
Last
Use
Longest
Period
clean/sober
Caffeine
Nicotine
Alcohol
Marijuana
Barbiturates
Heroin
Cocaine
Inhalants
LSD
PCP
Designer Drugs
Benzodiazepines
Prescription
Opiates
Other
Cage Screen:
Have you ever thought you needed to cut down on your drinking/drug use?
____Yes ____No
Have you ever been annoyed by other people’s criticism of your drinking/drug use?
____Yes ____No
Have you ever felt guilty about your drinking/drug use?
____Yes ____No
Have you ever used alcohol/drugs as an eye opener to get you going in the morning or to treat a hangover?
____Yes ____No
Rocky Mountain Psychiatry
303.750.2082
Suicidal Risk Assessment:
____No suicidal ideation
____Yes: suicidal ideation present (complete below)
Specify plan/intent:______________________________________________________________
Does patient have the means to carry out the plan?
____Yes
____No
If suicide attempted, complete the chart below:
Date
Means Tried
Pt Alone?
Pt Sought Help?
Hospitalized
Yes No
Yes No
Yes No
______________________________________________________________________________
Yes No
Yes No
Yes No
______________________________________________________________________________
Yes No
Yes No
Yes No
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Does the patient endorse relief at failing the attempt(s)?
____Yes
____No
Does the patient currently endorse feeling hopeful that
his/her problems will resolve w/o suicide?
____Yes
____No
Can patient currently endorse one or more reasons to live?
____Yes
____No
Is there a family history of suicide?
____Yes
____No
If yes, who?
________________________
Self-Injurious Behavior History:
Does the patient have a history of self-mutilation or
other forms of intentional self-injury?
____Yes
____No
If yes, specify the form of self-injurious behavior______________________________________
______________________________________________________________________________
Date of last self-injury:____________________________________
Rocky Mountain Psychiatry
303.750.2082
Violence History
Patient has a history of violent behavior (including fights, use of weapons, and/or cruelty to animals):
____Yes ____No
If yes, specify:_____________________________________________________________________
Does the patient have a history of aggressive behavior (including bullying, threatening, intimidating, and/or
destruction of property)
____Yes ____No
If yes, specify:_____________________________________________________________________
Does the patient have a history of other antisocial behavior (including fire setting, lying, school truancy,
theft)
____Yes ____No
If yes, specify:_____________________________________________________________________
Criminal History:
Does patient have a history of arrests:
____Yes
____No
If yes, specify:_____________________________________________________________________
Does patient have a history of DUIs
____Yes
____No
If yes, specify:_____________________________________________________________________
Does patient have pending legal charges?
____Yes
____No
If yes, specify:_____________________________________________________________________
Probation/Parole?
____Yes
____No
If yes, specify:_____________________________________________________________________
Rocky Mountain Psychiatry
303.750.2082
Trauma History:
Type of Abuse
Age at Onset
Perpetrator
Duration
Sexual
___________
_____________
_____________
Physical
___________
_____________
_____________
Emotional
___________
_____________
_____________
Neglect
___________
_____________
_____________
Verbal
___________
_____________
_____________
Other:
Patient witnessed traumatic event(s)?
____Yes
____No
If yes, specify:_____________________________________________________________________
Additonal traumatic events?
____Yes
____No
If yes, specify:_____________________________________________________________________
Significant loses?
____Yes
____No
If yes, specify:_____________________________________________________________________
Other personal significant life events?
____Yes
____No
If yes, specify:_____________________________________________________________________
Rocky Mountain Psychiatry
303.750.2082
Psychiatric History:
Date of first psychiatric symptoms:___________________
Specify:__________________________________________________________________________
Date of first psychiatric treatment:___________________
Inpatient treatment (Include any drug and/or alcohol rehab):
Location: (hospital, city)
Dates of Admission
Reason for Admission
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Outpatient treatment (include drug/alcohol rehab and psychotherapy):
Location: (hospital, city)
Dates of Admission
Reason for Admission
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Medication History
Name of Medication
Dates of Treatment
Benefits
Side Effects
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Rocky Mountain Psychiatry
303.750.2082
Family Psychiatric History: (M= maternal& P= paternal)
Disorder
List family member(s) with positive history for each disorder:
Alcoholism _____________________
Personality Disorder ________________
Drug Addiction__________________
Suicide ___________________________
Anxiety Disorder_________________
Bipolar Disorder ____________________
Panic Disorder ___________________
OCD _____________________________
Schizophrenia ____________________
PTSD _____________________________
Depression _______________________
ADHD ____________________________
Dementia ________________________
Other _____________________________
Primary Caregivers in Childhood and Adolescence
(Check all that apply):
____ Biological mother
____ Biological father
____ Stepfather
____ Stepmother
____ Adoptive mother
____ Adoptive father
____ Foster parents
____ Older sibling: M/F
____ Aunt/Uncle
____ Paternal grandmother
____ Paternal grandfather
____ Paternal grandfather
____ Maternal grandmother
____ Other:
Describe parental relationships during childhood and adolescence:
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Developmental History:
Birth Problems
____No ___ Yes
If yes, specify____________________________
Developmental delays
____No ___ Yes
If yes, specify____________________________
Remarkable childhood illness
____No ___ Yes
If yes, specify____________________________
Rocky Mountain Psychiatry
303.750.2082
Head injuries
Level of Education:
____No ___ Yes
If yes, specify____________________________
Highest Level of Education Completed: GED High School College Masters Doctorate
Other Training:___________________________________________________________________________
Are you currently registered in school?
Yes
No
If yes, specify:_____________________________________________________________________
Are you interested in furthering your education?
Yes No
If yes, specify:_____________________________________________________________________
History of learning disability?
Yes No
If yes, specify:_____________________________________________________________________
School Involvement:
Education Program:
Overall Grade Status:
Conduct:
Activities:
Sexuality:
____ Heterosexual
Regular
A/B Student
Suspensions
Sports
____Homosexual
Honors
C/D Student
Detention
Clubs
____Bisexual
Special Ed
Failing Courses
Frequent Reprimands
Band/Choir
____Transsexual
Alternative
Other
____ Sexually Inactive
Contraception
Yes No
If yes,specify:______________________________________________________________________
Sexual Dysfunction Yes No
If yes,specify:______________________________________________________________________
Marital Status
Primary Relationship Status
Duration
Primary Relationship Status
Duration
Living with partner___
_______
Separated ____
_________
Married ____
_______
Widowed ____
_________
Never Married ____
_______
Unmarried____
_________
Divorced ____
_______
Number of times married/divorced and dates:
_______________________________________________________________________________________
Rocky Mountain Psychiatry
303.750.2082
Quality of primary relationship (circle all that apply): stable, unstable, supportive, unsupportive, distant,
intense, rapidly changing, other________________________
If you are not together with someone, are you dating?
____Yes
____No
If yes, specify:_____________________________________________________________________
Work History
Present employment____________________________________ How long in job?____________________
Describe what you do: _____________________________________________________________________
Longest job patient held:___________________________________________________________________
Frequent job changes?
_____ Yes
____No
If yes, explain____________________________
List prior types of employment:______________________________________________________________
Current Employment Status (Check all that apply):
___ Job earnings
___ Workman’s Comp
___ Temporary work disability
___ Unemployed
___ SSDI
___ SSI (pending/current)
___ Alimony
___Benefits
___ No source of income
___ Self employed
___ Charity donation
___ Significant other’s job earnings
Do you have difficulty managing finances?
___ Yes
___No
If yes, specify:_____________________________________________________________________
Family Structure (spouse/partner, children, parents, siblings, other significant people)
Name/relationship
Gender
Age Financially Resides in
Quality of
dependent
household
relationship
on patient?
F M
Yes No
Yes No
F M
Yes No
Yes No
F M
Yes No
Yes No
F M
Yes No
Yes No
F M
Yes No
Yes No
F M
Yes No
Yes No
Please specify any difficulties in your family relationships:
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Rocky Mountain Psychiatry
303.750.2082
Social Relationships (check all that apply and comment on any items checked)
Social Feelings:
___Connected to others
___Inhibited or inadequate
___Comfortable alone
___Feelings of inferiority
___ Isolated
___Dependent on others approval
___Avoidant/uninvolved
___Controlling of others
___Lonely
___Judgmental/critical of others
___Alienated from community
___Fear of abandonment
___Suspicious of others
Friends and Acquaintances:
___Many acquaintances and close friends
___Some acquaintances and few close friends
___A few acquaintances and a few friends
___Minimal acquaintances and friends
Quality of Relationships with Friends
___Stable
___Distant
___Unstable
___Supportive
___Intense or rapidly changing
Describe quality of relationships:
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Spiritual Beliefs of Affiliations
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Rocky Mountain Psychiatry
303.750.2082
Hobby and Leisure interests:
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Community Service:
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Military History:
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Rocky Mountain Psychiatry
303.750.2082